Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
School Physical Examination Form
Your information
Student Full Name
Date of Birth
____ / ____ / ________
School Name
Grade Level
Parent / Guardian Name
Parent Phone Number
Parent Email
Home Address
Additional details
Please bring to your visit: immunization records
Medical Conditions Checklist
Current Medications
| Medication | Dose | How often |
|---|---|---|
Allergies
| Allergy | Reaction |
|---|---|
Vision or Hearing Concerns
Physical Activity Limitations
Parent / Guardian Signature
Date
School Physical Examination Form template from formisoft.com. formisoft.com/intake-templates/school-physical-registration